Friday, March 10, 2017

The Best Strategy To Address The Proliferation Of Prescribers

MPS Newsletter Ideas of Reference 2017, Number 1, Volume XLX

When I got home this evening I opened up a copy of the Minnesota Psychiatric Society newsletter Ideas of Reference. I was greeted by the above graphic and an accompanying story on the differences between psychiatrists and psychologists. There were even some bar graphs on the relative biomedical training comparing psychiatrists, nurse practitioners, physician assistants, and a proposed trivial training period for psychologist prescribers. I can only surmise that there is some initiative to create psychologist prescribers.

It should be obvious to any casual reader of this blog that as a medical psychiatrist and neuropsychiatrist, I don't think that anyone has better training than psychiatrists to prescribe medications and diagnose mental disorders and associated medical and neurological disorders. My first letters on this matter date back to 1988 with the CAAP v. Rank legislation in California that proposed that psychologists should have admitting privileges to hospitals. The same national group was getting active in trying to convince state legislators to allow psychologists to prescribe medications. To somebody who has been steeped in biomedicine, why somebody with no training would want to take a crash course to prescribe a niche of medications while knowing nothing about general pharmacology or physiology is a mystery to me. The early advocates were explicitly concerned about making money. There is nothing wrong with that, but it should be equally understandable why a highly trained person might find that approach somewhat appalling.

Over the years, I tried with no success to rally the troops not so much against any political group but always arguing for a tight professional organization whose goals was to bring all psychiatrists up to speed in order to practice state-of-the-art psychiatry. As a professional organization that is all you can do. The American Psychiatric Association tries to pull it off, but there are too many political conflicts of interest. For years the APA has clearly been more aligned with managed care organizations and the American Board of Medical Specialties and the American Board of Psychiatry and Neurology against the membership. People may deny it but that has been the net effect. Instead of the goals of independent life long learning and state-of-the-art psychiatry, the vigor of the organization has been dissipated on shaky political alliances and special interest politics. Instead of defending the organization and its members there have been concessions to people grandstanding in Congress. There have also been concessions to the cost rhetoric of both the government and managed care organizations and the current collaborative care rhetoric as psychiatric reimbursement from those organizations has become trivial and the infrastructure required to treat severe disorder - destroyed.

For the last 30 years, there has been a constant war of attrition in state legislatures everywhere against the idea that you probably should have medical training in order to prescribe medications. There is a break with reality in that physicians with the highest level of training also have the highest levels of accountability. Any interested citizen living in a state where there are a lot of nonphysician prescribers should ask themselves if all of those prescribers are held to the same standard or not? What level of training does it take in a crash course to equal my 8 years of medical training? How do politicians with no knowledge of medical training themselves make these decisions? Is the decision based on public safety - their usual standard for investigating physicians - or is it something else? I would submit that it is always something else?

Getting back to the title of this post I will comment on a few strategies that are probably too little and too late at this point. These are things I have been talking about for 30 years frequently to the annoyance of colleagues who prefer a head-in-the-sand approach:

1. State-of-the-art psychiatry: I was buoyed by a presentation on neuropsychiatry at the Madison conference this year and think that teaching and talking about these concepts needs to be more widespread. There is no better way to up your game than to take the thinking in the field to an entirely different level.

2. Politics: Physicians in general depend far too much on the kindness of strangers. The amount of money that physicians have given to politicians looking for a modest break (like maybe there should be a limit on who is qualified to prescribe medication) is legendary at this point. That is billions of dollars wasted just so the Obama administration could sit physician representatives down in a room and tell them their job was to sit there, shut up and support Obamacare. Physicians and psychiatrists cannot afford to squander blood, sweat, and treasure on people who only know how to exploit physicians. That includes anyone supporting maintenance of certification (MOC), maintenance of licensure (MOL), managed care organizations, or pharmaceutical benefit managers. That includes anyone supporting the various reasons why physicians have to sit down at the end of a busy day and spend another 3 to 4 hours on paperwork before they can go home.

3. Know who your friends are: Any manager who suggests that you need to be on a team comprised of nonphysicians when you are perfectly fine practicing independently is not your friend particularly when some of these people with no accountability start to tell you how to practice medicine. They can do that because they have the full support of the administration. Managed care companies that burn physicians out and hire more and more "prescribers" are not your friend. In this case the focus is on a nonmedical profession prescribing. While shocking it is also the logical conclusion of decades of more and more non-physicians who are often practicing in specialty clinics and seeing patients in regular rotation with subspecialists. The entire trend is driven not by expertise but by the managed care mantra of how to ration care but still make money. The current collaborative care model supported by the APA is a recipe for getting rid of psychiatrists either entirely or replacing them with somebody who can sit, look at a guideline and say something on the phone.

The team approach is also a management tool to make it seem like all team members are equal. If one of the specialists with a particular skill set is gone the patient can be seen by anyone. The encouraged egalitarian approach by management is clearly biased away from any particular expertise and toward generic and presumably less expensive prescribers.

4: Competition: When all of the geniuses in state legislatures max out the number of "prescribers" any psychiatrist out there needs to ask themselves: "Now what?" Well if anyone had been listening 30 years ago, psychiatry would be in a much better place right now. Instead, everyone jumped on the managed care bandwagon and three decades of decidedly poor quality care. The only hope that I see is doing what every other successful specialty does to survive managed care - get out and form your own specialty groups that compete on quality rather than the lack of competition. There are some physicians groups who become independent and try to out managed-care the managed care companies. By that I mean that they optimize billing, hire their own non-physician prescribers, and when the patient's financial resources are depleted - send them back to the managed care company. That is not a quality approach that will allow physicians to distinguish themselves from the typical managed care model.

5: High ethical standards: You can't impress anyone sitting in an office and prescribing Prozac. You are even less impressive if you are charging a lot of money for a brief appointment. You are least impressive if that appointment involves the prescription of an addictive drug. You can't get by with the managed care assembly line approach and do good work. Offer a high quality product for reasonable value and nobody can compete with that today - because there are few (as in hardly any) high quality products. Do not be surprised if no managed care company wants to contract with you. Do not be surprised if government payers will not reimburse you at levels that allow you to stay in business. It is definitely more ethical to work on your own than accept trivial reimbursement for stereotypical poor care.

6: Understand rhetoric: Physicians as a group really don't understand rhetoric or politics very well. They think that they are insulated from the fray and avoid confrontations. They never understand that bullshit and fake newsworks by leveling the playing field at some level for anyone who is arguing that they have equivalent knowledge or skill. In the worst case scenario, I have heard many physicians praising prescribers for some quality or another that generally had nothing to do with technical skill. The only way to preserve the integrity of a profession is to not engage in these pointless arguments and invest that time, energy, and mental work in advancing the profession at the national and local level. How many district branches have journal clubs, scientific meetings, and clinical discussions on state-of-the-art treatment on a routine basis? Not many I would guess and yet there is always time for these political squabbles. The commonest reason I hear that these learning activities don't occur is that everyone is "busy" and doesn't have enough time. Everyone is busy because their time is wasted managed care companies, the federal coding and reimbursement scheme, the mandatory and inefficient electronic health record, redundant maintenance of certification exercises, and pharmaceutical benefit managers.

7: The myth of the "prescriber" shortage: There should be no doubt in anyone's mind that the most commonly prescribed classes of psychiatric medications are overprescribed. The idea that we need more "prescribers" to provide even more of these medications flies in the face of that very fact. Do we need more ADHD experts to provide more stimulants or more anxiety experts to provide benzodiazepines? The answer is clearly no. There are only two interests being served by the prescriber shortage myth at this time and those are the health care systems that would prefer to equate all mental health treatment with the prescription of medications and the people manufacturing and selling the medications. A health care system that is flush with prescribers can certainly do a lot of billing and it is good for public relations, but it is unable to provide any quality psychiatric treatment.

Psychotherapy services and practically all psychiatric services have been adversely affected by the prescriber shortage myth. Right now there is a far greater shortage of behavior therapists for anxiety and post-traumatic stress disorders than there is of prescribers. In the case of patients with severe psychiatric illnesses and addictions these same health care systems that advertise prescribers do not provide adequate treatment environments for the psychiatric treatment of severe disorders and addictions. All care is funneled into a 10 or 15 minute appointment every three months focused on initiating or maintaining a medication - whether that is the best course of action or not.

Psychological testing is also discriminated against. The clearest example is the association of learning disorders with ADHD. Most studies show that at least 1/3 of people with ADHD have associated learning disorders. There are currently some managed care companies that not only have no psychologists to do this testing, they only allow for testing based on "medical necessity" whatever that might be. Psychologists that do testing are essentially managed right out of managed care companies or are so unavailable that it takes months or longer to do the testing. My speculation is that any quality improvement program on this issue for any managed care company would indicate either inadequate levels of testing and/or overdiagnosis of ADHD. It could easily be accomplished by looking at the number of ADHD prescriptions and determining if any testing had been done. It turns out managed care companies are the worst at determining the level of prescribing, psychotherapy and psychological testing needed to treat any population of people with mental illness.

Those are a few of my ideas just looking at the graphic. I am sure that I will have some more posts on this in the future. My main point this evening is that it is certainly understandable to try to fight this battle with special interest politicians but it is generally a battle that cannot be won at that level. Politicians will deplete time and money and give you nothing in return. There are just too many people who think that they should be able to prescribe medications irrespective of their training relative to the training of physicians. The only way to beat them is to excel and pull away looking at them in the rear-view mirror.

One thing is for sure - if I come to your clinic to see a Cardiologist - I better be seeing a Cardiologist and not a prescriber.

George Dawson, MD, DFAPA

Supplementary:

In thinking a little bit more about the current MPS approach, I came up with an alternative. I would ask MPS members to send in all of the medical problems and diagnoses they have made in the course of their practice on a month to month basis and compile them on the web site. That would go a long way toward differentiating medical and psychiatric practice from non-medical mental health practice. I would include diagnosing and treating complications of medical treatment. That would make more of an impact than the current infographic.

Attribution:

The graphic at the top is from the referenced source. I am a member and Past President of the MPS and a Distinguished Fellow of the APA. Use of this graphic is for commentary purposes and does not imply endorsement of me by the MPS or APA, although that should be fairly obvious.

As far as the graphic goes I realize that I am not the target audience here, but even with that premise the graphic appears to seriously dumb down what I do on a daily basis. That is one of the central problems in trying to condense and compare 8 years of education and training to someone with essentially no training at all in medicine.

8 comments:

Thank you for advocating tirelessly for the quality of the profession. Although it sounds like you have gotten little in results over the years, there still has to be someone out there fighting the good fight.. and maybe in the process inspire a few of the younger clinicians such as myself to advocate as well.

"Although it sounds like you have gotten little in results over the years...."

You are correct Victor.

If it impossible to change things in the face of conflict of interest. Any work that a guy like me can do is easily cancelled out by psychiatrists promoting managed care and any of the failed models I have listed. That conflict of interest is never discussed even though being a well paid employee of a managed care organization is a much greater incentive to do what they want than a piece of pizza is to prescribe a certain drug.

I will say that in the process, I have developed a great respect for the independent practitioners who practice outside of these organizations. They don't operate under these constraints but they do need to make sure they are producing an ethical and high quality product. It is no accident that the business and government forces oppressing all physicians comes down the hardest on them. It should be very clear that the people who run the healthcare system consider independent practitioners a problem and want to put them out of business.

I am not saying it is impossible to practice high quality psychiatry under onerous management - but it is very difficult because the entire model is not consistent with quality care.

Great post! Here's an illustrative anecdote. My husband and I are both self-employed, so we get our insurance through the exchange, meaning we get the cheapest plan we can find, and then pay out of pocket to see doctors who aren't in network. We switched plans this year and needed to pick a new PMD, because the one we've been seeing for the last 30 years is not in their network. We picked a doctor close to our home who seemed to get good reviews, including ones that said he listens to his patients. That sounded promising. My husband scheduled an appointment for a baseline checkup, and was only permitted to see the nurse practitioner. He said she was helpful. My husband has a PhD in Math, and his wife is a physician, and he thought it was just fine that he never even said hello to the PMD. What are less-informed people supposed to think? I refuse to see the NP, on the grounds that I will not be treated by someone with less experience, training, and knowledge than I have.

Physicians have inside information on how this system works. I posted my experience when my wife was prescribed a second course of antibiotics for severe ear pain. She had never had ear infection in her life. I had her see an ENT specialist who saved her life:

Thanks for that link. I have known Lee Beecher for decades at this point - since I first wrote him on the CAPP v. Rank issue when he was the President of MPS back in 1987. There is no better example of how direct service to patients rather than working for health care organizations improves quality and the integrity of the field.